Category: Uncategorized

A Hayekian Defense of Evidence-Based Medicine

May 11, 2016• 5

BY ANDREW FOY, MD

It’s a lousy Saturday morning in Southeastern Pennsylvania. The 100-mile bike ride I had scheduled, the first century of the year, was cancelled at 5 AM due to inclement weather. I’ve been scanning my Twitter feed ever since.

I only joined Twitter yesterday, so I’m a bit obsessed at this point. The synapses in my prefrontal cortex are getting fresh hits of dopamine every time I land on another exciting science/political story, journal article, or blog that’s been tweeted about. Yes, I’m a nerd.

Through Twitter, I was introduced to Michel Accad less than 24 hours ago. He’s a cardiologist, philosopher, writer, and creator of the blog “Alert and Oriented”. Over last evening and this morning, I read most of his blog articles as well as a few research papers he has authored. In short, I think he’s a fantastic writer and very intelligent guy but I have to take issue with a recent piece titled “The devolution of evidence-based medicine”. In it, he praises Anish Koka’s recent article on this site titled, “In defense of small data”. I know Anish personally; he is brilliant and paradoxically, he positively covered my own research using big data in another recent article.

More Than Adequate

May 11, 2016

By KOFI JONES

CMS recently unveiled a massive regulatory overhaul of Medicaid managed care requirements. Despite the fact that it’s being called a “mega-reg,” and taking some heat for its 1400+ page size, there’s certainly some interesting reading contained within, particularly for the telehealth community.

It’s all about network adequacy standards.

Health plans are regulated by states or CMS and measured based on their ability to demonstrate the adequacy of their in-network providers. How many are there? What’s the availability by specialty? Do consumers understand which providers are in-network? What does access look like in terms of wait times and distance? Answering these questions are the key to meeting the standard.

A Comprehensive Strategy For Primary Care Payment Reform in Medicine

May 10, 2016• 16

By MOSTASHARI, KOCHER and McCLELLAN

farzad_mostashari Strengthening primary care has been a core goal of health care payment reform over the past several years. Primary care physicians are the cornerstone of the health care delivery, directing billions of dollars of follow-on care. With better support, the models presume, primary care doctors could guide their patients toward a better health, direct them to the right care when needed, and in so doing, bring down unnecessary medical costs. Moreover, especially if coupled with payment reforms that can support better coordination with specialist practices, these reforms can provide an alternative to health system employment and health care consolidation, thus buoying competition in local markets.

The most recent effort toward this goal lies at the heart of the recently announced Comprehensive Primary Care Plus (CPC+) program. This program doubles down on the kinds of “medical home” payment and delivery reforms that were the hallmarks of previous Medicare initiatives, most notably the Comprehensive Primary Care Initiative, which in its first two years showed significant improvements in some dimensions of quality – but so far has generally failed to show reductions in overall costs significant enough to offset the per-member per-month (PMPM) payments to primary care practices to support their reforms. While some medical home payment reforms have shown both savings and outcome improvements, overall results have been mixed particularly in Medicare, with the result that the CMS actuaries have not yet “certified” any such medical home model as leading to overall spending reductions.

Actually, Medical Errors are the Leading Cause of Death

May 9, 2016• 20

By SAURABH JHA, MD

flying cadeucii Josef Stalin famously said: one death is a tragedy; one million is a statistic. Perhaps 250, 000 preventable deaths from medical errors, according to an analysis by Makary and Daniel in the BMJ, maketh a Stalin.

The problem with Makary’s analysis, which also concluded that medical errors are the third leading cause of death, isn’t the method. Yes, the method is shaky. It projects medical errors from a series of thirty five patients to a country of 320 million, which is like deciding national spice tolerance on what my family eats for dinner.

The problem with Makary’s analysis isn’t that it is full of assumptions. Assumptions are inevitable in biomedical research, and abundant in health services research. Researchers of medical errors must determine whether a bad patient outcome, such as death, was avoidable. Bad outcomes lie in a spectrum between inevitability and preventability. If every death is inevitable doctors are rendered impotent, and if every death is avoidable doctors are rendered omnipotent (FWIW, I prefer omnipotence).

Who Owns What Happens Next?

May 9, 2016

By JEFF GOLDSMITH

flying cadeucii As Medicare and private insurers continue to struggle with implementing accountable care organization- and population-linked payments, an increasing amount of attention is being paid to a less expansive but almost as complex method of shifting risk to hospitals and physicians: paying a fixed price for an episode of care, or bundling. The key question about bundling is: Who owns the responsibility for assuring a successful recovery from clinical interventions?

Bundled payment is designed to focus attention on care coordination and delivering a complete clinical solution to a complex medical problem. Unless resource consumption and the patient’s progress through the episode are managed tightly, hospitals and others accepting bundled payments are at risk of significant operating losses as well as poor clinical results.

Acute care over quickly

As most of my friends and all of my family know, I spent a good portion of 2015 intensively using the health system I have worked in for 40 years. It was an eye-opening experience. Beginning in December 2014 with a scary cancer diagnosis, then nerve grafting in my right hand in October 2015 and a hip replacement in November, I experienced three surgical interventions in three different places (two academic health centers away from home and my local community hospital in Virginia). All of the interventions were successful, and after a period of recovery and rehabilitation, I returned, healthy and disease free, to my active life.

The biggest surprise in my patient experiences: how fast the acute phase of my care was over! In two of my three surgeries, I was out on the street with a sheaf of discharge papers in my hand, barely conscious of the magnitude of the intervention within 24 hours of waking up from surgery. In the third case, pain control issues prolonged my hospital stay for about a week.

An Obamacare November Surprise?

May 8, 2016• 10

By JIM PURCELL

flying cadeucii An article this week in Politico entitled “Obamacare’s November Surprise” observes that premium announcements for Obamacare’s exchanges should be published around November 1, and that the news will be offputting, to say the least. Double digit increases from beleaguered insurers are likely, reflecting substantial structural and financial flaws within the exchanges as currently designed. The article suggests that this might be problematic for Democrats.

I’m doubtful whether, even if there is November rate shock, that it will substantially derail the then Democratic candidate, which absent some stunning intervening event will be Hillary Clinton. While the ACA is a natural extension of what Ms. Clinton has advocated for decades, she did not design the exchanges, and to hold her responsible for their design flaws seems a tad unfair. Likewise, she always has taken the position that rather than repeal the ACA, its flaws should be rectified. Easily said, a very safe position to take, and fair enough as it goes.

But what IS going on with the exchanges and the many co-ops that have failed? What happened?

Making Sense of MACRA

May 8, 2016

By THE EDITORS

A special webinar for THCB readers.

Looking Back From 2019: Why the Republicans Nationalized Healthcare

May 7, 2016• 4

By JOE FLOWER

Screen Shot 2016-05-08 at 11.41.21 AM It was the Mother of unintended consequences.

By the time of the 2016 elections, health plans, hospitals and health systems had squeezed and consolidated and trimmed and cut costs under the gun of lower Medicare reimbursements and the new rules of Obamacare — but mostly they had adapted. Most of them had survived.

On November 9, the country woke to find itself with a Republican President-elect, a Republican majority in the House, and a Republican majority of 55 in the Senate. The Grand Old Party was dedicated to repealing #EveryWord of the Affordable Care Act, the hated Obamacare which was, after all, “destroying the country,” “the worst thing to happen to the country since the Civil War,” and “equivalent to slavery.”

The changes to healthcare did not wait until Inauguration Day, much less until the 115th Congress could assemble to gut the law. They began instantly.

November 9, of course, was just nine days into the annual Open Enrollment period for plans under the Affordable Care Act exchanges. Many of the 12.7 million who had signed up for 2016 could see that the subsidies they were getting through the exchanges would likely disappear in the wake of the election, and decided not to sign up. “Why chance it?” as Betty Cornwall of New Rhodes, Kentucky, put it to Fox News’ Megyn Kelly.

Health plan strategists, masters of not getting blindsided by risk, decided that it was a bad idea to sign up millions of people for plans without knowing what would happen to the law. They did not want to get stuck with serving people who did not pay, and did not want to get blamed for dumping people after they had signed up. So most large health plans withdrew immediately from the exchanges, before many more people could sign up, draining the exchanges in many states of any choices at all.

How to Save American Football

May 7, 2016• 2

BY GEORGE LUNDBERG, MD and DAVID METZNER

Screen Shot 2016-05-07 at 9.43.44 AM

American football is a great sport. It offers, requires, nurtures, and rewards speed, skill, strength, cunning, offensive and defensive strategic thinking, courage, judgment under pressure, competitive spirit, reliance on teamwork, a requirement for exquisite timing, and resolve. Football teaches a participant how to get up and get back at it after being knocked down again and again, a great life lesson. And football has the capacity to engender huge dedicated fan bases.

Unfortunately, as the supreme contact sport, it is also a collision sport and thrives on a degree of inherent violence. Thus, injuries are expected and common. Most heal, usually without any disability. Some do not.

Misunderestimating the AMA

May 6, 2016• 10

By BRADLEY FLANSBAUM, MD

CMS just released their proposed MACRA regs (Cliff Notes version), and as you could expect, every specialty society and interested party dug in and critiqued. The rule runs a thousand pages and will have a substantial effect on the future of provider payment. In case, you have not heard.

Each organization will cut their sections of interest out, parse them, synthesize their analysis, and return a long letter to CMS. They will offer the correct paths on which the agency should proceed–lest they go forward uninformed taking down entire blocks of the healthcare system on account of willful neglect and ignorance. The letters will start with a friendly salutation along the lines of, “We commend the Secretary on her wisdom and hard work….BUT, we have an eensy weensy problem on some issues,” and so the turn goes.

The inpatient docs will hit the rough patches as they relate to fitting hospital-based practitioners into an outpatient focused model; the nephrologists will sound off on integrating dialysis payments within a medical home; the surgeons will focus on attribution of adverse post-op events weeks after patients leave the hospital; and the pathologists will just throw their hands up and say, “huh, should we just skip this party.”